PATIENT: Andy Hall
SURGEON: Gary Sanchez, M.D.
PREOPERATIVE DIAGNOSES: Right carotid stenosis
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Right carotid thromboendarterectomy.
This patient was monitored with EEG. There were some depressions when we clamped, but this returned to normal after
re-establishing circulation.
ANESTHESIA: General
DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient’s right side of the neck was prepped and draped in
the usual manner. An incision was made across the medial border of the sternocleidomastoid. The platysma was divided. The
common carotid artery was localized. We then put a LigaLoop around it, and then we isolated the external and internal carotid
arteries and placed LigaLoops around them. We saw the hypoglossal nerve. We put the retractors in and retracted on the
upper end of the wound, and then we gave the patient heparin and proceeded with the arteriotomy.
After placing clamps on the internal, common, and external carotid arteries, the arteriotomy was done. This was a severe
stenosing atherosclerotic plaque. This was removed. We then sutured the artery up with a 5-0 Prolene at the distal and then
at the proximal and meeting in the middle, producing back bleeding, and then we closed the artery. The wound was then
closed in layers after placing a Hemovac in the wound. The wound was approximated with 2-0 chromic, 2-0 plain, and
surgical staples on skin. A dressing was applied. Patient tolerated the procedure well and was transferred to the recovery
room in stable condition.
Pathology Report Later Indicated: Atherosclerotic plaque. Evacuated clot material. What is the ICD 10, HCPCS, CPT
CPT
1. Right carotid thromboendarterectomy- 35301.CPT
2. Anesthesia for Right carotid thromboendarterectomy - 00350 CPT
3. EEG monitoring - 95812 CPT
ICD
1. Right carotid stenosis -I65.21 ICD.
PATIENT: Andy Hall SURGEON: Gary Sanchez, M.D. PREOPERATIVE DIAGNOSES: Right carotid stenosis POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE...
PREOPERATIVE DIAGNOSES: Right carotid stenosis POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Right carotid thromboendarterectomy. This patient was monitored with EEG. There were some depressions when we clamped, but this returned to normal after re-establishing circulation. ANESTHESIA: General DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient’s right side of the neck was prepped and draped in the usual manner. An incision was made across the medial border of the sternocleidomastoid. The platysma was divided. The common carotid artery was localized. We then...
PREOPERATIVE DIAGNOSIS: Symptomatic right internal carotid artery stenosis. POSTOPERATIVE DIAGNOSIS: Symptomatic right internal carotid artery stenosis. OPERATIVE PROCEDURE: 1. Right carotid thromboendarterectomy with patch placement. 2. Intraoperative electroencephalogram monitoring. INDICATION: This 30-year-old woman has a tight right internal carotid artery stenosis. She has had an episode of amaurosis fugax. She has some other medical problems that also complicate her overall situation, but she has a significantly tight stenosis that is symptomatic, and I would recommend an endarterectomy for this. The...
Gary Sanchez, M.D. PREOPERATIVE DIAGNOSIS: Histiocytic tumor of the right shoulder Indications: This patient is a 62-year-old gentleman that was diagnosed with a histiocytic tumor of the right shoulder and requested surgical intervention. POSTOPERATIVE DIAGNOSIS: Same PROCEDURE PERFORMED: Excision of plexiform fibrous histiocytic tumor of the right shoulder. ANESTHESIA: General endotracheal with approximately 20 cc of tumescent solution prepared by adding to 1 L of Ringer's lactate, 25 cc 2% Xylocaine, 1 cc of 1:100,000 epinephrine, and 3 cc of...
PREOPERATIVE DIAGNOSIS: Scar right parietal region. POSTOPERATIVE DIAGNOSIS: Same. SURGICAL FINDINGS: 3 x 1 cm elevated scar right parietal region of scalp. SURGICAL PROCEDURE: Excision scar of scalp. ANESTHESIA: General endotracheal anesthesia, plus 2 cc of 1% Xylocaine and 1:100,000 epinephrine. PROCEDURE: The scalp was prepped with Betadine scrub and solution, draped in the routine sterile fashion. The lesion was anesthetized with 2 cc of 1% Xylocaine with 1:100,000 epinephrine, mostly for the epinephrine effect. After a wait of four...
SURGEON: Gary Sanchez, M.D. PREOPERATIVE DIAGNOSIS: 10 cm lipoma, right thigh POSTOPERATIVE DIAGNOSIS: 10 cm lipoma, right thigh PROCEDURE PERFORMED: Excision of 10 cm right thigh lipoma INDICATIONS: Tyra Olsen is a very pleasant 32-year-old female, who presented with a large lipoma of her right thigh. She wants to have this resected. She understands the surgery and the risks of bleeding, infection, postoperative fluid collections and wishes to proceed. PROCEDURE: The patient was brought to the operating room, given IV...
LOCATION: Inpatient, Hospital PATIENT: Karla Stevens SURGEON: John Hodgson, M.D. PREOPERATIVE DIAGNOSES: 1. Spinal stenosis, without neurogenic claudication. 2. Spondylolisthesis, L4-L5. 3. Right radicular pain L5 root. INDICATIONS: Karla is a 52-year-old woman who is a baker and stands on her feet for many hours a day. She was diagnosed with spinal stenosis and spondylolisthesis and continues to have low back pain. She understands the risks and potential complications and problems that may occur from the surgery and wishes to...
LOCATION: Outpatient, Hospital PATIENT: Shelby Winston SURGEON: Larry P. Friendly, M.D. PREOPERATIVE DIAGNOSIS: Recurrent right inguinal hernia. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES PERFORMED: Repair of recurrent right inguinal hernia. HISTORY: This is an 80-year-old female who has previously undergone a right inguinal hernia repair performed earlier this year. The repair was a type repair, and she, subsequently, returned with complaints of a new bulge in the right groin. An ultrasound was performed which demonstrated evidence of a right inguinal hernia. She...
PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Large left inguinal hernia, direct. PROCEDURE: Repair of large direct left inguinal hernia with Prolene Hernia System Mesh (PHS) and resection of lipoma of the spermatic cord. FINDINGS: Large direct left inguinal hernia and large lipoma of the spermatic cord. DESCRIPTION OF PROCEDURE: After routine preparation, the patient was prepped and draped under general anesthesia in supine position. The bladder was decompressed with a Foley catheter. An incision was made in the left...
PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Large left inguinal hernia, direct. PROCEDURE: Repair of large direct left inguinal hernia with Prolene Hernia System Mesh (PHS) and resection of lipoma of the spermatic cord. FINDINGS: Large direct left inguinal hernia and large lipoma of the spermatic cord. DESCRIPTION OF PROCEDURE: After routine preparation, the patient was prepped and draped under general anesthesia in supine position. The bladder was decompressed with a Foley catheter. An incision was made in the left...
LOCATION: Inpatient, Hospital PATIENT: Charlene Tipton SURGEON: Loren White, M.D. PRE/POSTOPERATIVE DIAGNOSIS: Right breast mass. PROCEDURE(S) PERFORMED: Right breast open biopsy. ANESTHESIA: General endotracheal. INDICATIONS: Charlene is a 66-year-old female who presented with a palpable right breast mass. A biopsy was done which showed atypical cells and was felt to be suspicious for cancer. She also had a highly suspicious lesion on ultrasound in the same area. An open biopsy was recommended. Possible definitive treatment with simple mastectomy was also...